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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. -------------------------------------------------------- ---------------------------------------- ---------------- (Complete in Duplicate) Date Issued ........ ---------------------------------------- ---• ---------- —I.This. Permit Expires 1 Year From Date Issued T 7_ Application is hereby made to the San Joaquin Local Health Distrid for a permit to consti-6 t and install the work herein described. This application is made in compliance with Coun.tyQ�cl.inqnce No. 549. 7—YS— .22®--o S JOB ADDRESS AND LOCATIQN-__ ------- VC Owner's Name.-•-----•- - ---------XX Ic =... ........ Z.....- ------ - -------------------- -------==-------- Phone!.-------•--------_----------_-- ---------------------- - -- ---------- - fit------ - -------------- Address..--------------------- ------- Contractor's ------------...................................... Name--.-- -- ------------- - ----- - -----------------•----•"-------------'----------------- Phone_--------------------------------- -----------------------7- - - ------ ------ Installation will serve: Residence ffj"Apartment House'E] Commercial [] Trailer CouA E] Motel 0 Other E] Number of living units.1------Number of bedroom's Number of baths' Lot siL -------------------------- Water Supply: Public system El Community system Ej Private �epth'+6°Water Tagle/S.__ft. I Character of soil to a depth of 3 feet: Sand E] Gravel [j Sandy Loam Clay Loam U] Clay ❑ Ad i be C] Hardpan E] Previous Application Made: (If yes,date----------------- No [r""'New Constructiofil Y6t,No E] FHA/VA: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet. "Septic an iancefiom neareWWetll, on------------------- r ---------------- ---------- 2' No: of compartments----- ------------ ----------Liquid depth-1---�4-----------------Ca'acify-/a, % . . — i f P Dispzi Field: Distance from nearest well 6� 1,4.�_ '4tance from found t' n )-A ---.-----Distance to nearest lot line-- Number of lines------ —------------- ... Length of 030S---LP---�Vidth of trench.11-val each oun'4�10 ....... ------ line_ . Type of filter material___ -SAe,_e ---Depth of filter material----.__AfO1�----Total length....... Seepage Pit: Distance to nearest well----------------------`Distance from foundation__..---------------Distance to nearest lot line----------------- ❑ Number of-pits----------------------Lining I material------------------------Size: Diameter-----------------------Depth-•--------P-------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining materiall--—----------------------------- .. ..... --------------------gals, Size: Diameter-----------------------------------De pfh_7!- . ------------------ -----------------Liquid Capacity! Privy. Distance from 'nearest well-_--._.._-"---------------- ----------------------Distance from nearest building.--" -------------------------------- ❑ ix Distance to nearest-16t line- ------------------------ -- -------------------- ------------------------- ------------------------------------4t--- -------------------- Remodel n -------:-------------m--------------------------------T--------------------------- --- ---------4-----------------------------9------------ ------- ----NOITIF6= , ___j?---- or I 1P.1ri I . --- —— — -1------------------------------ T ----------------------------------------------- -------- ------------------ ------------ ----- ------------------------------ -----------z---- --------------------------------------- 'i ------------ ----------__--------- ----------------------------- ---------------------------------------------------------------------------------------- ------------------------------------------------------- --------- I hereby certify that Ihai'�e-prepared f kis'�ipplicaf ic;n and that the work will be �one in accordance with Sari Joaquin County ordinances, State laws',' a'ndh'r-11es and regulatXIn't of the San Joaquin Local Health District. (Signed).. 2 7e --------- low ------------------------ ner and/or Contractor) - ----- BY:--- ------ ------------------------------------------------------------------------------------------------------------(Title)-------------------------- ... .............. . ----- ---- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse sidle). ONIII ® E RT)4�NT Uc� APPLICATION ACCEPTED -yv'('/-,/----------- -------------- DATE- --------------------------- REVIEWED BY-------------------------------------- ------------- DATE-----------------------------4------------------------------ ------------ —----- ------------------------------ IDATE----- BUILDING PERMIT ISSUED------------------------------- ------------------------------------------------------------------.. ------ ------------------------------------------ Alterations anilor recommendations:-- ---------------------------------- --------------------------------- --------------- ------------ ------------ ---------------- ------------------------ ----------------------------------------------------------------- ------------------------------------------------------------ ---------------------------------------------------------------- ---------------- ----------- ---------- ------------------- ---- --------- -- -- -------- ------------------------------------------------------------------------------------------ ----- --- ----------------- ------------------- ------- ......... -R____ V44 ---- - --------- to_, --------------------------- --- ------- FINAL,INSP�QPU,8 SAN JOAQUIN-LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tr*CYr California r6-7 REVISCO 13-59 F.F.rP.2M 15.60